4-H Eligibility Form - Brazos

DECLARATION OF ELIGIBILITY FORM
1.
PARENT/GUARDIAN /COUNTY EXTENSION AGENT - Complete This Section
In accordance with 4-H policy, provided by our local Extension office, I respectfully request (check one):
Academic eligibility information only
Academic eligibility information and authorization to receive an excused absence from school
Date of Activity(s): _________________ Name of Activity:_______________________________
2.
3.
4.
Signature of Parent/Guardian: __________________________________________________
I hereby certify that __________________ is a member of 4-H in Brazos County and is scheduled to
participate in this activity representing 4-H. He/she will be under the supervision of Texas A&M AgriLife
Extension faculty and/or our agency’s designated volunteer leader.
_________________________ _______________________________________________________
Date
County Extension Agent
PRINCIPAL - Complete This Section
5.
Check one:
I do certify that the student is academically eligible to participate in the above mentioned
extracurricular activity.
I do not certify the student because he/she is NOT academically eligible to participate in
the above mentioned extracurricular activity.
6.
Check one:
An excused absence will be granted.
An excused absence will not be granted.
Does not apply.
7.
Signed: ______________________________________________ Date: __________________________
Principal or Designee
______________________________________________
Name of School
Instructions on back
Educational programs of the Texas A&M AgriLife Extension Service are open to all people without regard to race, color, sex, disability, religion, age, or national
origin. The Texas A&M University System, U.S. Department of Agriculture and the County Commissioners Courts of Texas Cooperating.

WORK FROM THE TOP DOWN
Parents/Guardians fill out the top portion including:
1. The academic eligibility information boxes and the Date of the activity, the Name of
Activity,
2. The parent/guardian signature
3. AND the Name of the child
Extension office
4. Our office fills in the date and uses a signature stamp for the County Extension Agent
signature.
The principal of your child’s school will fill in the bottom portion including:
5. The academic eligibility confirmation box(es)
6. The absence box(es)
7. The Principal’s signature with the name of school and date signed
The Extension office will then need a copy for our documentation and the child will keep the
original to be presented, if needed, to the event supervisor or the school.
The copy may be sent any of the following ways:
Mailed to our office at: 2619 Highway 21 W., Bryan, TX 77803
Scanned and emailed to ejbesser@ag.tamu.edu or gjhoyt@ag.tamu.edu
Faxed to #979-775-3768
Brought in and we will make the copy for you